Exercise Interventions for PTSD: A Systematic Review and Network Meta-Analysis of Overall Effects, Comparative Effectiveness, and Ranking Uncertainty

Background/Objectives: Exercise has been investigated as an adjunctive intervention for post-traumatic stress disorder (PTSD), but the comparative effectiveness of exercise modalities remains uncertain. This study evaluated the effects of exercise and movement-based interventions and whether the available evidence supports a reliable hierarchy of exercise modalities. Methods: PubMed, APA PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), and ScienceDirect were searched through 31 January 2026 for randomized controlled trials in adults with PTSD or clinically significant symptoms. Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool, and network confidence using Confidence in Network Meta-Analysis (CINeMA). Post-treatment PTSD severity was synthesized using random-effects meta-analysis with restricted maximum likelihood and Knapp–Hartung adjustment. A frequentist network meta-analysis used the strict exercise network as the principal comparative framework, with a broad exercise and movement-based network evaluated as a sensitivity analysis. Results: Twenty studies were included. Fifteen trials (863 participants) contributed to the meta-analysis, showing reduced PTSD symptoms (Hedges’ g = −0.49, 95% confidence interval (CI) −0.69 to −0.28; I2 = 40.2%), although the 95% prediction interval crossed the null (−1.01 to 0.04). Eleven trials meeting the strict physical-exercise definition and providing compatible raw post-treatment data showed a similar effect (g = −0.44, 95% CI −0.66 to −0.20). The strict network included five nodes and 754 participants. No exercise modality showed clear superiority over active control, and no head-to-head comparisons between exercise modalities were available. Resistance exercise had the highest probability of ranking first, whereas yoga had the highest surface under the cumulative ranking curve (SUCRA) value (0.809); confidence in all network comparisons was very low. Conclusions: Exercise and movement-based interventions may reduce PTSD symptoms, but current evidence does not support a reliable hierarchy of exercise modalities. Rankings should not be interpreted as clinical superiority without direct comparative evidence.